More than two dozen patients were rushed into an emergency room in Macon, Ga., over two days with the same array of life-threatening symptoms, including organ failure and sepsis, flummoxing doctors. But after their breathing tubes were removed, the patients revealed a common thread: All had taken what they believed were Percocet pills they had bought on the street.

Although they looked like the prescription painkillers at first glance, the pills they took were nothing like what they expected. They were fakes, an amalgam of substances — including one never before seen in Georgia — pressed into a pill that mimicked those a doctor would prescribe. Instead of a low dose of Percocet, the users were slammed with a near-lethal combination of other drugs, including U-47700, a synthetic opioid the Drug Enforcement Administration said has been linked to dozens of deaths.

“I’d never seen any medication or drug present with multi-organ failure, mimicking stroke, sepsis, all at the same time,” said Gregory Whatley, an emergency room doctor at Navicent Health in Macon who called Georgia Poison Control after realizing multiple patients took the same small yellow pills. “Not to be cavalier, it was a real killer.”

Law enforcement officials and medical professionals say that counterfeit opioid pills like those found in Macon have been flooding the illicit drug market and have been sickening — and killing — those who are seeking out powerful prescription drugs amid a worsening national opioid crisis. There is widespread fear that users who believe the prescription drugs are safe — because they are quality-controlled products of a regulated industry — could now unwittingly end up ingesting potent cocktails of unknown substances. In many places, the pills contain fentanyl, a synthetic drug that is driving a nationwide surge in overdose deaths.

The rise of counterfeit pills is in part a consequence of well-intentioned actions taken to prevent overdose deaths; as states enact strict prescription limits and closely monitor doctors, fewer authentic painkillers are available. While some opioid abusers turn directly to heroin or fentanyl, the cartels and drug dealers are filling the void, and meeting demand, with pills they have manufactured to look like the originals.

And that trade is in­cred­ibly lucrative, officials said, without the need to obtain the tightly controlled pills. One kilogram of illicit fentanyl — far cheaper than heroin or oxycodone — can produce 1 million counterfeit pills, netting $10 million to $20 million in revenue, according to the DEA.

The pills also are filled with fentanyl analogues — different formulas of the drug concocted to skirt U.S. drug laws — and other chemicals that evade drug screenings and have unknown effects on the human body, until people like those in Macon overdose.

‘Pretty good knockoffs’

The pills or their component parts come to the United States from either Mexico or China, officials say. In Mexico, cartels process the pills and ship them over the southwest border. Chemicals needed to make the pills are typically bought via the dark web from China. When the chemicals reach the United States, many of the fake pills are created in home operations, akin to the meth labs that proliferated about a decade ago.

The chemicals are bound together using pill presses, which can churn out thousands of pills at a time and are supposed to be registered with the DEA. In fiscal 2011, Customs and Border Protection confiscated two pill presses at the Port of Los Angeles; in fiscal 2017, the agency confiscated 396.

In Arizona, the DEA has seized at least 70,000 counterfeit pills this year, said Doug Coleman, special agent in charge of the Arizona field office. In August, Coleman’s agents and the Tempe police seized 30,000 counterfeit oxycodone pills after a traffic stop in the city that was part of an operation targeting the Sinaloa cartel. The blue pills contained fentanyl and were stamped with “M” and “30.” They were so realistic-looking that the manufacturer of the drugs, Mallinckrodt Pharmaceuticals, called the DEA’s Phoenix office to say they were “pretty good knockoffs,” Coleman said. Mallinckrodt said it has supported and worked with law enforcement on the problem of fake pills.

“I think that these pills are going to be becoming more and more popular, and I think we’ll see more and more of them coming across,” Coleman said.

In other cases, typically those involving small-time dealers, pills or the chemicals used to make them are coming through the mail, such as one case in a small South Dakota town that authorities say is indicative of the burgeoning problem.

Prosecutors allege that Trevor Harden was expecting a package at the small brick post office in Chamberlain, S.D., in June that contained 20,000 counterfeit oxycodone pills. Authorities say he planned to sell the drugs to minors in the town of 2,300 on the Missouri River; postal inspectors later intercepted a second package destined for Harden containing an additional 20,000 counterfeit pills. All were made of fentanyl.

Assistant U.S. Attorney Jennifer Mammenga said Harden ordered the pills on the dark web, and prosecutors believe the pills originated in China but were routed through California before arriving at a postal processing facility in Rapid City, S.D.

“They think these are prescription pills, they’re safe,” Mammenga said. “But they’re really pressed pills that are made in China, and we have no idea what’s in them.”

Harden pleaded guilty to charges of attempting to possess and intending to distribute fentanyl; his defense attorney declined to comment.

Mammenga said it is difficult to imagine why Harden needed 40,000 pills: “There’s less than a million people in the state of South Dakota. There’s 2,300 people in the town he lives in.”

Churning out counterfeits

Police have discovered one of the major challenges is that dealers are making the pills inside private homes, where people are mixing fentanyl and other substances and churning counterfeit pills out of presses.

“We’ve worked cases where we’ve taken off pill presses where they can make 5,000 pills an hour, and that’s pretty doggone substantial,” said T.J. Jordan, assistant director at the Tennessee Bureau of Investigation.

Authorities in Utah broke up what they allege was a multimillion dollar international drug ring run out of a home in Cottonwood Heights, just south of Salt Lake City, where they found pill presses and bulk powder substances.

Prosecutors allege that six young people purchased pill presses, dies and stamps to make the pills look legitimate and sold them in an online store. Authorities allege they bought fentanyl and alprazolam — the anti-anxiety drug used in Xanax — from China. Authorities found nearly 100,000 pills that were made to look like oxycodone and Xanax at a stash house a few miles away.

On Long Island, DEA agents entered a detached garage behind a small white home in North Babylon, N.Y, and allegedly found Daniel O’Neil and Frankie Morano wearing hazmat suits and respirator masks. Prosecutors say the men were operating a pill press, manufacturing counterfeit oxycodone pills out of fentanyl. The men were charged with conspiracy to distribute and intent to distribute a substance containing fentanyl.

Morano’s attorney, Randy Zelin, said he is working toward a plea agreement so his client can “get the help he needs to put this behind him and rebuild his life and rebuild his family’s life.” O’Neil’s lawyer, Nancy Lynn Bartling, said her client plans to plead guilty once an agreement with the government is finalized. He was, she said, a drug addict and did this “to basically pay for his addiction, to buy more drugs, to feed the vicious cycle.”

The Macon, Ga., outbreak occurred over a weekend in early June, and most of the people who took the pills ended up in the emergency room at Navicent, a hospital about 80 miles southeast of Atlanta. Doctors gave them multiple doses of a drug used to reverse opioid withdrawal. None worked.

After talking to patients and colleagues, Whatley said he kept coming back to a conversation with one man.

“The key word he said was ‘Percocet,’ ” Whatley said. “He said he bought Percocet from a dude on the street for back pain, and another dude said the same thing.”

Gaylord Lopez, head of the state’s poison control center, was watching television late on a Sunday when he got the call from Whatley. How, he wondered, could people be so sick off one pill?

He began contacting all of the hospitals in and around Macon and found others reporting patients with the same symptoms. The Bibb County Sheriff’s Office was soon called in to investigate.

“The first thing that ran through my mind is, ‘Oh my lord, is this an epidemic that is going throughout this region and are we seeing the first of it?’ ” said Bibb County Sheriff David Davis.

Officials quickly put out the word: Do not take yellow pills marked “Percocet” that were purchased on the street. The drugs were found to contain U-47700, a synthetic opioid analogue, and cyclopropyl fentanyl, an opioid that had never been seen in Georgia. The pills had to be sent to a special lab out of state for testing.

Officials at Navicent said they saw 28 cases in two days, with patients ranging from the 20s to late 50s. At least four people died.

“This is not the heroin addict that you see in the movies,” said Christopher Hendry, chief medical officer of Navicent. “This is soccer moms and everyone else you could not imagine to see a narcotic addiction in.”

Betty Jean Collins, 60, and her husband, Henry Howard, 69, told the Macon Telegraph that they ran out of their prescription medication and bought Percocet on the street. Collins said she had open-heart surgery, and her husband has back problems. Both overdosed and survived. Collins told the paper that after two days in the hospital, “my chest is still burning and my legs are on fire.” The couple could not be reached for comment.

The cases in Macon soon stopped, but two months later, another outbreak of overdoses from counterfeit pills occurred in Warner Robins, about 20 miles south of Macon.

“For us now to see something in such a toxic form in these synthetic opioids, it’s definitely a game changer for us,” said Nelly Miles, a spokeswoman for the Georgia Bureau of Investigation.